Healthcare Provider Details

I. General information

NPI: 1144805078
Provider Name (Legal Business Name): SOMEWHERE OVER THE SPECTRUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WEBSTER SQUARE RD BLDG 1
BERLIN CT
06037-2329
US

IV. Provider business mailing address

120 WEBSTER SQUARE RD BLDG 1
BERLIN CT
06037-2329
US

V. Phone/Fax

Practice location:
  • Phone: 860-420-3800
  • Fax: 860-420-3801
Mailing address:
  • Phone: 860-420-3800
  • Fax: 860-420-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: COURTNEY WELCH
Title or Position: CO-OWNER
Credential: MBA
Phone: 860-420-3800